Cognitive Trajectories after Postoperative Delirium

Division of Geriatric Medicine and Meyers Primary Care Institute, University of Massachusetts Medical School, Worcester, MA 01605, USA.
New England Journal of Medicine (Impact Factor: 54.42). 07/2012; 367(1):30-9. DOI: 10.1056/NEJMoa1112923
Source: PubMed

ABSTRACT Delirium is common after cardiac surgery and may be associated with long-term changes in cognitive function. We examined postoperative delirium and the cognitive trajectory during the first year after cardiac surgery.
We enrolled 225 patients 60 years of age or older who were planning to undergo coronary-artery bypass grafting or valve replacement. Patients were assessed preoperatively, daily during hospitalization beginning on postoperative day 2, and at 1, 6, and 12 months after surgery. Cognitive function was assessed with the use of the Mini-Mental State Examination (MMSE; score range, 0 to 30, with lower scores indicating poorer performance). Delirium was diagnosed with the use of the Confusion Assessment Method. We examined performance on the MMSE in the first year after surgery, controlling for demographic characteristics, coexisting conditions, hospital, and surgery type.
The 103 participants (46%) in whom delirium developed postoperatively had lower preoperative mean MMSE scores than those in whom delirium did not develop (25.8 vs. 26.9, P<0.001). In adjusted models, those with delirium had a larger drop in cognitive function (as measured by the MMSE score) 2 days after surgery than did those without delirium (7.7 points vs. 2.1, P<0.001) and had significantly lower postoperative cognitive function than those without delirium, both at 1 month (mean MMSE score, 24.1 vs. 27.4; P<0.001) and at 1 year (25.2 vs. 27.2, P<0.001) after surgery. With adjustment for baseline differences, the between-group difference in mean MMSE scores was significant 30 days after surgery (P<0.001) but not at 6 or 12 months (P=0.056 for both). A higher percentage of patients with delirium than those without delirium had not returned to their preoperative baseline level at 6 months (40% vs. 24%, P=0.01), but the difference was not significant at 12 months (31% vs. 20%, P=0.055).
Delirium is associated with a significant decline in cognitive ability during the first year after cardiac surgery, with a trajectory characterized by an initial decline and prolonged impairment. (Funded by the Harvard Older Americans Independence Center and others.).

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    • "Furthermore, to the best of the authors' knowledge, no previous study has explored short-term cognitive outcomes. Delirium experienced in hospital can and does clear (see, e.g., Saczynski et al., 2012). The mean duration of episodes has been quoted as being between 1 and 8 days in acute care settings (see, e.g., Inouye et al., 2007) although episodes may last a little longer, with a mean of 11.5 days in older long-term care residents (see, e.g., Cole et al., 2012). "
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    ABSTRACT: The aim of this study was to examine early cognitive performance after a delirium in elderly general hospital patients. Patients were divided into a delirium (n = 47) and a control (n = 25) group. One week before discharge and after delirium had cleared in the first group, all patients completed a neuropsychological test battery (The Cambridge Cognitive Examination-Revised [CAMCOG-R]). Group differences in cognitive performance were analyzed adjusting for differences in baseline sociodemographic and clinical variables. Adjusting for group differences in baseline variables, the delirium group performed significantly worse than the control group on CAMCOG-R; its subdomains language, praxis, and executive functioning; and on Mini Mental State Examination derived from CAMCOG-R. The occurrence of delirium in hospital thus detrimentally affects early cognitive performance.
    The Journal of nervous and mental disease 09/2014; 202(10):732-737. DOI:10.1097/NMD.0000000000000182 · 1.81 Impact Factor
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    • "In our study, the period of the hospitalization before operation increases the possibility of postoperative delirium increased. As noted elsewhere, as postoperative delirium is very likely to lead to a chronic decline of cognitive function, efforts to prevent postoperative delirium must be very important29). "
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    ABSTRACT: Objective Postoperative delirium is a common complication in the elderly after surgery but few papers have reported after spinal surgery. We analyzed various risk factors for postoperative delirium after spine surgery. Methods Between May 2012 and September 2013, 70 patients over 60 years of age were examined. The patients were divided into two groups : Group A with delirium and Group B without delirium. Cognitive function was examined with the Mini-Mental State Examination-Korea (MMSE-K), Clinical Dementia Rating (CDR) and Global Deterioration Scale (GDS). Information was also obtained on the patients' education level, underlying diseases, duration of hospital stay and laboratory findings. Intraoperative assessment included Bispectral index (BIS), type of surgery or anesthesia, blood pressure, fluid balance, estimated blood loss and duration of surgery. Results Postoperative delirium developed in 17 patients. The preoperative scores for the MMSE, CDR, and GDS in Group A were 19.1±5.4, 0.9±0.6, and 3.3±1.1. These were significantly lower than those of Group B (25.6±3.4, 0.5±0.2, and 2.1±0.7) (p<0.05). BIS was lower in Group A (30.2±6.8 compared to 35.4±5.6 in group B) (p<0.05). The number of BIS <40 were 5.1±3.1 times in Group A, 2.5±2.2 times in Group B (p<0.01). In addition, longer operation time and longer hospital stay were risk factors. Conclusion Precise analysis of risk factors for postoperative delirium seems to be more important in spinal surgery because the surgery is not usually expected to have an effect on brain function. Although no risk factors specific to spinal surgery were identified, the BIS may represent a valuable new intraoperative predictor of the risk of delirium.
    Journal of Korean Neurosurgical Society 07/2014; 56(1):28-33. DOI:10.3340/jkns.2014.56.1.28 · 0.52 Impact Factor
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    • "Delirium is a serious neuropsychiatric syndrome, characterized by disturbances in attention and other cognitive functions (Bisschop, de Rooij, Zwinderman, van Oosten, & van Munster, 2011). The prevalence of delirium is observed in 10–62% of all hospitalizations and is more prevalent in the elderly (van Munster et al., 2008), which is associated with a prolonged length of stay, high rate of institutionalization, and increased morbidity and mortality (Saczynski et al., 2012). "
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    ABSTRACT: Few studies have examined the association between perioperative blood transfusion and postoperative delirium (POD) in aged patients undergoing total hip replacement surgery. In this prospective study, 186 patients older than 65 yr undergoing elective unilateral total hip replacement surgery were enrolled. Of those, 94 patients were randomly assigned to the restrictive strategy transfusion strategy group, in which red blood cells were transfused in order to maintain 10.0 g/dL > hemoglobin ≧ 8.0 g/dL. Ninety-two patients were randomly assigned to the liberal transfusion strategy group, in which red blood cells were transfused in order to maintain hemoglobin ≧ 10.0 g/dL. POD was diagnosed by confusion assessment method. The baseline characteristics of patients, the length of hospital stay, the incidence of POD, myocardial infarction, stroke, wound infection, pulmonary embolism, and the transfusion volume were recorded. No difference was observed in the baseline characteristics, the length of hospital stay, and the incidence of POD, myocardial infarction, stroke, wound infection, and pulmonary embolism between the two groups (P > 0.05). The proportion of patients transfused with red blood cell and frozen plasma was decreased in the restrictive transfusion group compared with the liberal transfusion group (P < 0.05). In conclusion, restrictive transfusion does not influence the incidence of POD but reduces blood transfusion. Thus, restrictive transfusion may serve as an effective and safe strategy for aged patients following total hip replacement.
    Archives of gerontology and geriatrics 07/2014; DOI:10.1016/j.archger.2014.03.009 · 1.53 Impact Factor
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